Failure in Tube Feeding Management
Penalty
Summary
The facility failed to provide appropriate care and services to a resident receiving tube feedings, as evidenced by observations and staff interviews. Resident R20, who has a history of diabetes, dysphagia, and hemiplegia following a stroke, was admitted to the facility with a requirement for tube feedings. The resident's care plan indicated the need for tube feedings due to dysphagia. A physician's order specified that the resident was to receive Glucerna 1.5 via peg-tube at a rate of 80 ml per hour from 8:00 p.m. to 8:00 a.m. However, during observations on two consecutive days, it was noted that the tube feeding formula container was not dated when opened, which is against the manufacturer's guidelines that require the formula to be used within 24 hours of opening. Interviews with staff, including a Registered Nurse and the Director of Nursing (DON), confirmed that the tube feeding container was left hanging beyond the recommended time without a date and time, increasing the risk of using the formula beyond the 24-hour limitation. The DON acknowledged that the formula should not be used after being opened for 24 hours and that the container should be removed when the feeding is stopped at 8:00 a.m. The Nursing Home Administrator and the DON confirmed the facility's failure to provide appropriate care and services to residents receiving tube feedings, as evidenced by the lack of adherence to the manufacturer's guidelines and facility policy.
Plan Of Correction
Resident R20's tube feeding was taken down and hung with the correct date on the next administration. The facility has determined that all residents receiving tube feeding have the potential to be affected if the tube feeding is not dated properly. All residents receiving tube feeding, bottle checked for proper dates and correct orders. In-service education programs regarding the Tube Feeding Policy were conducted separately with licensed staff by the Director of Nursing Services (DON), or designee. The Director of Nursing Services (DON), or designee, will conduct observations of dating tube feeding to take place three days per week for four weeks, then bi-weekly for one month, then monthly for one month. Findings of this audit will be discussed with the Resident Council. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met.